Publications by Year: 2024

In hand trauma, the uninjured forearm has been touted as the ideal site for ectopic banking in digit/hand amputations. Here, we describe the temporary ectopic implantation and subsequent replantation of a partially amputated hand and highlight the "Three R's" - Recovery, Rehabilitation, and Revision over the first year of recovery.

Background and Objectives: Despite the promise of phage therapy (PT), its efficacy in prosthetic joint infection (PJI) management is unknown. Much of the current literature is largely limited to case reports and series. Materials and Methods: In order to help inform power calculations for future clinical trials and comparative analyses, we performed a systematic review and proportional meta-analysis of early PT outcomes to provide a preliminary assessment of early phage therapy treatment outcomes for cases of PJI. Results: In a search of available literature across MEDLINE (Ovid, Wolters Kluwer, Alphen aan den Rijn, The Netherlands), Embase (Elsevier, Amsterdam, The Netherlands), the Web of Science Core Collection (Clarivate, London, UK), and Cochrane Central (Wiley, Hoboken, NJ, USA) up to 23 September 2023, we identified 37 patients with PJIs receiving adjunctive PT. Patients most frequently reported Staphylococcal species infection (95%) and intraarticular phage delivery (73%). Phage cocktail (65%) and antibiotic co-administration (97%) were common. A random-effects proportional meta-analysis suggested infection remission in 78% of patients (95% CI: 39%, 95%) (I2 = 55%, p = 0.08) and 83% with a minimum 12-month follow-up (95% CI: 53%, 95%) (I2 = 26%, p = 0.26). Conclusions: Our study provides a preliminary estimate of PT's efficacy in PJIs and informs future comparative studies.

Hip fractures exceed 250,000 cases annually in the United States, with the worldwide incidence projected to increase by 240-310% by 2050. Hip fractures are predominantly diagnosed by radiologist review of radiographs. In this study, we developed a deep learning model by extending the VarifocalNet Feature Pyramid Network (FPN) for detection and localization of proximal femur fractures from plain radiography with clinically relevant metrics. We used a dataset of 823 hip radiographs of 150 subjects with proximal femur fractures and 362 controls to develop and evaluate the deep learning model. Our model attained 0.94 specificity and 0.95 sensitivity in fracture detection over the diverse imaging dataset. We compared the performance of our model against five benchmark FPN models, demonstrating 6-14% sensitivity and 1-9% accuracy improvement. In addition, we demonstrated that our model outperforms a state-of-the-art transformer model based on DINO network by 17% sensitivity and 5% accuracy, while taking half the time on average to process a radiograph. The developed model can aid radiologists and support on-premise integration with hospital cloud services to enable automatic, opportunistic screening for hip fractures.

Spine disorders can cause severe functional limitations, including back pain, decreased pulmonary function, and increased mortality risk. Plain radiography is the first-line imaging modality to diagnose suspected spine disorders. Nevertheless, radiographical appearance is not always sufficient due to highly variable patient and imaging parameters, which can lead to misdiagnosis or delayed diagnosis. Employing an accurate automated detection model can alleviate the workload of clinical experts, thereby reducing human errors, facilitating earlier detection, and improving diagnostic accuracy. To this end, deep learning-based computer-aided diagnosis (CAD) tools have significantly outperformed the accuracy of traditional CAD software. Motivated by these observations, we proposed a deep learning-based approach for end-to-end detection and localization of spine disorders from plain radiographs. In doing so, we took the first steps in employing state-of-the-art transformer networks to differentiate images of multiple spine disorders from healthy counterparts and localize the identified disorders, focusing on vertebral compression fractures (VCF) and spondylolisthesis due to their high prevalence and potential severity. The VCF dataset comprised 337 images, with VCFs collected from 138 subjects and 624 normal images collected from 337 subjects. The spondylolisthesis dataset comprised 413 images, with spondylolisthesis collected from 336 subjects and 782 normal images collected from 413 subjects. Transformer-based models exhibited 0.97 Area Under the Receiver Operating Characteristic Curve (AUC) in VCF detection and 0.95 AUC in spondylolisthesis detection. Further, transformers demonstrated significant performance improvements against existing end-to-end approaches by 4-14% AUC (p-values < 10-13) for VCF detection and by 14-20% AUC (p-values < 10-9) for spondylolisthesis detection.

The supraspinatus tendon plays a crucial role in shoulder abduction, making it one of the common structures affected by injury. Clinically, crescent-shaped tears are the most commonly seen tear shape. By developing six specimen-specific, three-dimensional, supraspinatus-infraspinatus finite element model with heterogeneous material properties, this study aimed to examine the changes in tissue deformation (maximum principal strain) of the supraspinatus tendon due to specimen-specific material properties and rotator cuff tear size. FE models with small- and medium-sized full-thickness crescent-shaped tears were subjected to loads seen during activities of daily living and physiotherapy. Six fresh-frozen cadaveric shoulders were dissected to mechanically test the supraspinatus tendon and develop and validate FE models that can be used to assess changes in strain due to small (< 1 cm, equivalent to 20-30% of the tendon width) and medium-sized (1-3 cm, equivalent to 40-50% of the tendon width) tears that are located in the middle and posterior regions of the supraspinatus tendon. FE predictions of maximum principal strain at the tear tips were examined to determine whether failure strain was reached during activities of daily living (drinking and brushing teeth) and physiotherapy exercises (prone abduction and external rotation at 90° abduction). No significant differences were observed between the middle and posterior tear failure loads for small- and medium-sized tears. For prone abduction, there was a potential risk for tear progression (exceeded failure strain) for medium-sized tears in the supraspinatus tendon's middle and posterior regions. For external rotation at 90° abduction, one model with a middle tear and two with posterior tears experienced failure. For all daily activity loads, the strain never exceeded the failure strain. Our three-dimensional supraspinatus-infraspinatus FE model shows that small tears appear unlikely to progress based on the regional strain response; however, medium-sized tears are at higher risk during more strenuous physiotherapy exercises. Furthermore, differences in patient-specific tendon material properties are important in determining whether the tear will progress. Therefore, patient-specific management plans based on tear size may be beneficial to improve clinical outcomes.

BACKGROUND: Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development.

METHODS: We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment.

RESULTS: From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77).

CONCLUSIONS: Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi.

BACKGROUND: Growing interest has motivated recent studies to examine differences in recovery after sport-related concussion (SRC) by sex. However, heterogeneity in study design, participants, and recovery outcomes has led to mixed findings. Further work is needed to evaluate potential differences by sex and to investigate the role of related characteristics, such as sport contact-level, in recovery timelines. This study aimed to investigate whether concussion recovery trajectories differ by sex, considering a priori clinical and demographic covariates, and accounting for the sequence of recovery outcomes. Our secondary question was whether sport contact-level modifies the relationship between sex and time to outcomes. Using data from the Ivy League-Big Ten Epidemiology of Concussion Study, we included SRCs reported across five academic years; 2015-2020 (February 2020). We used Cox proportional hazards regressions to estimate associations between sex and time from injury to three outcomes: (1) symptom resolution, (2) return to academics, (3) return to full play, accounting for measured confounders.

RESULTS: Among 1160 SRCs (male, n = 667; female, n = 493) with complete data, median age overall was 20 years (25th-75th percentiles:19-21), and most occurred among athletes playing high-contact sports (78.0%). Males were slightly more likely to complete symptom resolution over time compared to females (HR = 1.18, 95%CI = 1.05-1.33), but results were attenuated in fully adjusted models (HR 1.13, 95%CI = 0.99-1.29). Similarly, the HR of full academic return for males compared to females was 1.22 (95%CI = 1.07-1.38), but was attenuated in fully adjusted models (HR = 1.11, 95%CI = 0.97-1.28). The HR of full return to play for males compared to females was 1.14 (95%CI = 1.02-1.28), and was attenuated after adjustment (HR = 1.06, 95%CI = 0.93-1.20) as well. The interaction between sex and playing a high/low-contact sport was not statistically significant across models, though differences were apparent.

CONCLUSIONS: Among a cohort of collegiate athletes with SRC, recovery timelines appeared similar between male and female athletes, adjusting for measured confounders. Differences by sex, considering sport contact-level, were evident and may be important clinically and in future studies. This study used robust methods, accounting for nesting in the sequence of RTP outcomes. Results inform concussion management protocols and planned qualitative work to further elucidate how collegiate athletes experience concussion recovery.

KEY POINTS: Heterogeneity in study design, participants, and recovery outcomes has led to mixed findings in determining differences in recovery trajectories after concussion by sex. We found that having longer time to symptom resolution, and also the sequence of having academic return before symptoms resolve and longer time to academic return were confounders in the relationship between sex and RTP timelines. Time to sequential recovery outcomes appeared similar between male and female athletes, adjusting for observable confounders. Further differences by sex were evident when considering contact-level, and may be important to consider clinically and in future research. Results indicate that differences in concussion recovery trajectories by sex may be largely attributed to and driven by differences in sports with a men's or women's team only, such as football, and this should be explored further.

BACKGROUND: Treatment strategies for meniscal tears range from nonoperative management to surgical intervention. However, national trends in cost-related outcomes and patient factors related to the failure of nonoperative management remain poorly understood.

PURPOSE: To describe the costs associated with nonoperative versus operative management of meniscal tears in the 2 years after diagnosis and examine the relationship between patient characteristics and timing of surgery.

STUDY DESIGN: Cross-sectional study; Level of evidence, 3.

METHODS: This study was conducted using the MarketScan databases. Patients diagnosed with a meniscal tear without concomitant knee osteoarthritis between January 1 and December 31, 2017, were included. The primary outcome was the total cost of meniscal tear-related procedures-including insurance deductibles, coinsurance, and net insurance payments-in the 2 years after diagnosis. Procedures included were as follows: (1) surgery-including meniscectomy or meniscal repair; (2) physical therapy; (3) medication-including nonsteroidal anti-inflammatories, opioids, and acetaminophen; (4) intra-articular injections-including professional fee, hyaluronic acid, and corticosteroids; (5) imaging; and (6) clinic visits to orthopaedic specialists. Patients were grouped as having undergone early surgery (ES) (≤3 months of diagnosis), late surgery (LS) (>3 months after diagnosis), or no surgery (NS). Multivariate logistic regression was performed to determine the likelihood of undergoing surgery early and failing nonoperative treatment.

RESULTS: The study population included 29,924 patients with a mean age of 43.9 ± 12.9 years (ES: n = 9507 (31.8%); LS: n = 2021 (6.8%); NS: n = 18,396 (61.5%)). Complex (36.6%) and medial (58.8%) meniscal tears were the most common type and location of injuries, respectively. The mean cost of management per patient was $3835 ± $4795. Costs were lower in the NS group ($1905 ± $3175) compared with the ES group ($6759 ± $5155), while the highest costs were observed in the LS group ($7649 ± $5913) (P < .001). Patients who were men, >40 years, and with a bucket-handle or lateral meniscal tear were more likely to undergo surgery early. Patients who were men, <30 years, and with a complex tear or tear to the lateral meniscus were more likely to fail nonoperative management.

CONCLUSION: Nonoperative management had the lowest cost burden and should be recommended for patients with appropriate indications. However, if surgery is necessary, it should be performed earlier.

Background: Lower extremity reconstructive surgery is an evolving field wherein patients rely on accessible online materials to engage with their perioperative care. This study furthers existing research in this area by evaluating the readability, understandability, actionability, and cultural sensitivity of online health materials for lower extremity reconstruction. Methods: We identified the 10 first-appearing, educational sites found by searching the phrases "leg saving surgery", "limb salvage surgery," and "leg reconstruction surgery". Readability analysis was conducted with validated tools, including Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed with Patient Education and Materials Assessment Tool (PEMAT), while cultural sensitivity was measured with Cultural Sensitivity Assessment Tool (CSAT). A Cohen's κ value was calculated (PEMAT and CSAT analyses) for inter-rater agreement. Results: The mean SMOG reading level for websites was 13.12 (college-freshman reading level). The mean PEMAT understandability score was 61.8% and actionability score was 26.0% (κ = 0.8022), both below the 70% acceptability threshold. The mean CSAT score was 2.6 (κ = 0.73), exceeding the 2.5 threshold for cultural appropriateness. Conclusion: Online PEM for lower extremity reconstruction continue to fall below standards of readability, understandability, and actionability; however, they meet standards of cultural appropriateness. As patients rely on these materials, creators can use validated tools and positive examples from existing PEM for greater patient accessibility.